Original Article
Trichomonas, Candida, and Gardnerella in Cervical Smears of Iranian Women for Cancer Screening Narges Kalantari, Salman Ghaffari1, Masomeh Bayani2 Cellular and Molecular Biology Research Center, 1Department of Parasitology-Mycology, Faculty of Medicine, 2Infectious Diseases and Tropical Medicine Research Center, Babol University of Medical Sciences, Babol, Iran
Abstract Background: Trichomonas vaginalis, Gardrenella vaginalis, and Candida sp are responsible for 90% of vaginitis which has been reported as important risk factors for cervical cancer. Aim: This study aimed to find the prevalence of T. vaginalis, Candida sp, and G. vaginalis in women attended the cancer clinic charity, Babol, Iran and to identify the associated risk factors. Materials and Methods: This retrospective study carried out from 1996 to July 2012 on women who attended to a cancer screening program at the cancer clinics charity, Babol, Iran. Papanicolaou test and clinical examinations were performed for each woman. In addition to Papanicolaou test results, demographic data were collected. The data were analyzed with X2 test using SPSS software, version 18. Results: In total, 2511 out of 33600 (7.5%) cases had vaginal infections. A total of 71 (0.2%), 2248 (6.7%), and 192 (0.6%) of subjects were infected by T. vaginalis, Candida sp, and Gardnerella, respectively. The highest rate of infection was seen in 20-30 and 30-40 years age group. The frequency of vaginal ulcers was higher in trichomoniasis (14.1%). Conclusion: This study demonstrated that the prevalence of T. vaginalis, Candida sp, and Gardnerella was low among the studied population. Moreover, malignant cytological alternations were not seen in any infected women.
Keywords: Candida sp, Gardnerella vaginalis, pap smear, T. vaginalis Address for correspondence: Dr. Salman Ghaffari, Ganj-Afroz Ave, Department of Parasitology-Mycology, Faculty of Medicine, Babol University of Medical Sciences, Babol, Iran. E-mail: s3ghaff[email protected]
Introduction The Papanicolaou smear has been widely accepted as the model screening test for cervical cytology. However, recent reports have suggested some limitations for the test, such as low sensitivity and high false negative rates, which have forced many to revisit the utility of cytology as a primary screening.[1] The Papanicolaou smear, which is a cost-effective test, fast and acceptable to most patients, can also be use in the diagnosis of genital tract infections. In addition to Chlamydia trachomatis, herpes simplex virus and human immunodeficiency virus, Trichomonas Access this article online Quick Response Code:
Website: www.najms.org
DOI: 10.4103/1947-2714.125861
vaginalis, is the most common sexually transmitted diseases over the world. These agents have been proposed to act as cofactors to influence the progression of cervical human papillomavirus infection to high-grade lesions and cervical cancer.[2,3] Additionally, bacterial vaginosis (BV) and Candida sp are the most frequent vaginal disorders which may play a role in cervical carcinogenesis.[4,5] Although, T. vaginalis, BV, and Candida sp are responsible for 90% of infectious vaginitis; but the prevalence found for these infections are widely varied among different populations.[6] For example, T. vaginalis and Candida sp were diagnosed in 10% and 0.5% of the cytology tests in 1968 and in 3.4% and 22.5% in 1998 in Brazil.[7] Another study demonstrated that T. vaginalis, Candida sp and Gardnerella/Mobiluncus were respectively found in 12%, 5.8%, and 21.8% of pap smears of women in a prison in Brazil.[8] However, many studies have investigated the prevalence of infectious agents among the genital tract using Papanicolaou smear, but there are few studies on large populations of women who have been referred for cervical cancer screening.
North American Journal of Medical Sciences | January 2014 | Volume 6 | Issue 1 |
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Kalantari, et al.: Cervical infections and pap smear
In Iran, based on our best knowledge, most of the studies on genital tract infections by Papanicolaou smear were performed among symptomatic cases. The objective of this work was to study prevalence of T. vaginalis, Candida sp, and Gardnerella in women subjected to Papanicolaou smear at a clinic supported by Cancer Patients Aid Association, Babol, Iran and to identify the risk factors associated with each infective agent.
order to calculate the association of risk factors with vaginal infections.
Data analysis The data were analyzed by SPSS software, version 18.0 using descriptive analysis and Chi-squared test with a 5% statistical significance level and 95% confidence interval.
Materials and Methods
Results
Population study After obtaining approval letter with number 8929916 from the Ethical Committee of the Research Council of our organization, this retrospective study was carried out on women who attended to the cancer screening program at a clinic supported by Cancer Patients Aid Association, Babol, Iran. This center is a charity organization and established in 1996 in order to help people to increase their knowledge on cancer, diagnosis, and treatment. Breast and genital cancer were screened in the diagnostic clinic by clinical examinations and Papanicolaou test which were completely free of charge. Pap smear test was performed for any woman who attends this clinic, in addition to other clinical examinations, annually. Vaginal examination and taken smear was carried out by physician. The smears were fixed with methanol and send to clinical pathology laboratory. The smears were evaluated by a pathologist. This clinic also collects demographic data and other information based on clinical examinations and the Pap smear reports using a Bethesda system. This information includes the sample adequacy, the type of epithelium (e.g. squamous, glandular, and metaplastic), benign cellular alterations (e.g. inflammation), and the type of genital infections (e.g. T. vaginalis and Candida sp). Between 1996 and July 2012, the information from 33600 cases was archived. The files for all of the cases of T. vaginalis, Candida sp, and Gardnerella infections were retrieved. Also, files of 200 women without any infection (control group) were randomly recovered in
Overall, 2511 out of 33600 (7.5%) cases had vaginal infection. A total of 71 (0.2%), 2248 (6.7%), and 192 (0.6%) of the women were infected by T. vaginalis, Candida, and Gardnerella, respectively. A total of 142 out of 2511 (5.7%) cases had mixed infection. The minimum and maximum of age among women with trichomoniasis was 18 and 61 years and the mean of age was 34.7 years. The mean age of women infected with Candida and Gardnerella were 32.7 ± 8 and 32.8 ± 8.5, respectively which ranged from 14 to 67 and 17-60 years in that order. The mean age of women with coinfection and healthy women (control group) was 32.4 ± 9.2 and 34.6 ± 10.5 years, respectively which ranged from 17 to 67 and 18 to 73 years in that order. The age of one case infected with T. vaginalis and 12 cases infected with Candida were obtained as missing data. The highest infection rate of T. vaginalis and Candida were observed in the 30-40 age groups and for Gardnerella was seen in the 20-30 years age group. The highest rate of coinfection was also seen in the 20-30 years age group. The highest frequency rate of women in the control group was demonstrated in the 20-30 years age group followed by the 30-40 age groups [Table 1]. The lowest rate of trichomoniasis (1.4%) was demonstrated in women who used condom as their preferred choice of contraception, while the highest rate (2.7%) was seen in women who used other forms of contraception such as tubectomy or oral contraceptives. Furthermore, 13.8% of women who used intrauterine device (IUD) were infected with
Table 1: Prevalence of Trichomonas vaginalis, Candida sp, Gardnerella and coinfection in women attending to the cancer clinics charity, Babol, Iran, by age Infection Age group (years)
Mean±
T. vaginalis Candida Gardnerella Coinfection Control
34.7±10.2 32.7±8 32.8±8.5 32.4±9.2 34.6±10.5
N%
P value
50
Total
57.1 873.9 105.2 107 157.4
2028.6 86938.9 7941.1 6143 6633
2738.6 92341.2 6835.4 5135.9 6030
1420 31914.3 3116.2 1611.3 4321.6
45.7 381.7 42.1 42.8 168
70100 2236100 192100 142100 200100
0.09 0.001 0. 95 -
N. B: The mean age, standard deviation, and frequency of healthy women (control group) among different age group also mentioned. The numbers of trichomoniasis and candidiasis cases were 71 and 2248, but there was missing data on age of 1 tricomoniasis and 12 candidiasis cases. T. vaginalis: Trichomonas vaginalis
26
North American Journal of Medical Sciences | January 2014 | Volume 6 | Issue 1 |
Kalantari, et al.: Cervical infections and pap smear
This study demonstrated that 64.8% and 5.6% of women infected with T. vaginalis were also infected with Candida sp and Gardnerella, respectively. Coinfection was also demonstrated in women with candidiasis and Gardnerella infection [Figure 1]. The findings obtained in this study showed that about 4%-8.3% of
infected women with T. vaginalis remained infected in subsequent refers. Also, 59.3% of infected with Candida sp and 51.2% of infected women with Candida sp and Gardnerella remained infected in the next refer. Malignant cytological alternations were not seen in any infected women. 120 100 Percentage
Gardnerella and the lowest infection rate was observed in those used condom and other methods (0.05%). The infection rate of candidiasis was approximately similar in women who used different contraception methods and ranged from 82.7% to 87.3% [Table 2]. A total of 1.2% and 12.3% of healthy women used condom and IUD, respectively and the rest used other methods. Vaginal ulcers were demonstrated in 14.1% (10/71), 7.4% (167/2246), and 8.9% (17/192) of women infected with T. vaginalis, Candida sp, and Gardnerella, respectively [Table 2 and Figure 1]. Prevalence of genital infections in association with other factors including number of gravid, abortion, inflammation, residency, and presence of squamous cells are also shown in Table 2.
100
80
100
100
64.8
60
48.4
40 20
5.6
20.9
14.1
4.3 7.4
2.1
0
8.9
1
Figure 1: Prevalence of coinfection and ulcer in women attending to a clinics supported by Cancer Patients Aid Association, Babol, Iran. T, I, C, G, and U are Trichomonas, Infection, Candida, cancer Gardnerella, and ulcer, in that order
Table 2: Prevalence of Trichomonas vaginalis, Candida sp, and Gardnerella related to some risk factors and sign, in women attending to a clinics supported by cancer patients aid association, Babol, Iran Risk Infection Inflammation Severe Moderate Mild no Ulcer Yes No Squamous cells Yes No Abortion Yes No Gravid no 3 Contraception IUD Condom Natural and other Residency Urban Rural
Control
P value
18 9.4 89 46.6 189 6634.6
-
0
1677.4 207993
178.9 17591.1
-
a, 0.3; b, 0.002; c, 0.9
0
4100
1100
-
1725.8 4974.2
52924.3 164776
4423.9 14076.1
56 28 14472
a, 0.9; b, 0.000; c, 0.8
1322.8 245.6 1831.6
47423 112555 46322.4
3318.7 9453.1 5028.2
3518.8 9048.4 6132.8
a, 0.35; b, 0.16; c, 0.000
2/942.1 4/2861.4 55/20062.7
81/9882.7 255/29287.3 1699/203383.6
13/9413.8 15/2850.05 138/19876.9
212.9 61.2 15586.1
a, 0.01; b, 0.02; c, 0.05
6088.2 811.8
193388 27712.5
16988 2312
179 89.5 2110.5
a, 0.7; b, 0.09; c, 0.9
N% T. vaginalisaa
Candidab
Gardnerellac
79.9 37 52.1 2129.6 68.4
1516.8 88539.7 77334.6 42218.9
1014.1 6185.9
N.B. P value arranged in order of Trichomonas vaginalis, Candida sp, and Gardnerella infections. Note in regarding the association between candidiasis and number of gravidity and abortion and contraception, the P values were 0.000 and 0.02 which may resulted from number of cases in non infected women (200 cases). Also notice that missing data of Gravid number and contraception in noninfected population. a, b, and c represent P value of Trichomonas vaginalis, Candida sp and Gardnerella and the factors, respectively. IUD: Intrauterine device, T. vaginalis: Trichomonas vaginalis
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Kalantari, et al.: Cervical infections and pap smear
Discussion This study found that infection rate among the women attending to cancer screening program was low (7.5%). This result was obtained by Papanicolaou test which has some limitations such as less sensitivity.[1-9] It also demonstrated that Candida sp was the main cause of vaginal infection (6.7%) and T. vaginalis (0.2%) and Gardnerella (0.6%) had low prevalence rates among these women. Although, our study is confirmed by publications which indicate that candidiasis is the most common vaginal infection in most countries, but the prevalence rate of infective agents obtained from the current study was lower in comparison with other studies in the word and Iran.[10-13] For example, one study reported that the amount of candidiasis, trichomoniasis, and Gardnerella infection were 9.8%, 1.9%, and 0.7% in pap smear of women who participated in screening. [12] Adad et al., [7] studied 20,356 cases using Papanicolaou test in four decades in Brazil and found that low and high indices of infections belong to trichomoniasis (3.4%) and candidiasis (22.5%) from 1988 to 1998. Mehmetoglu et al.,[14] reported that vaginal infection identified in 17.7% (59 out of 332) of the cases by Pap smear and the prevalence of trichomoniasis was 0.6%. Also, Lessa et al.,[8] studied 672 patient records and demonstrated that the main cervical-vaginal colonization was due to Gardnerella/Mobiluncus (21.8%), followed by T. vaginalis (12%), and Candida sp (5.8%). Furthermore, the prevalence of BV, candidiasis, and trichomoniasis in asymptomatic subjects were found 0.4%, 1.1%, and 0.7%, in that order.[15] Although, different diagnostic methods were used in this study, its findings support our results. With consideration of the prevalence rate of T. vaginalis, Candida, and Gardnerella infections among asymptomatic cases in several reports,[5,13,15,16] the differences of the studied populations are the main possible explanation for dissimilarity between our findings and other publications. The current study showed that the highest prevalence rate of T. vaginalis (38.6%) and Candida (41.3%) infections and Gardnerella infection (41.1%) was seen in 20-30 years and 30-40 and age group, respectively. This finding is in agreement with results obtained from several studies which indicated that highest rate of trichomoniasis demonstrated in women at sexually active ages.[17-19] or BV was observed at reproductive ages.[20] This study found that, although moderate inflammation was a general manifestation in infected women, [8] trichomoniasis causes more inflammation (mild to sever) and ulcers in comparison to candidiasis and Gardnerella [Table 2]. Indeed, Trichomonas, Candida, and Gardnerella are considered as the simultaneous inflammatory events in genital tract.[12] 28
In regard to T. vaginalis and Gardnerella infections, the analysis of the behavioral marker showed that the prevalence of the infection was significantly lower in women whose husbands use condom as a contraception method. These results are in agreement with other publications which indicate that the rate of trichomoniasis and BV was less in those whose husbands used condoms than who did not.[18-22] Moreover, the current study found that the Gardnerella infection may be associated with IUD. This finding is supported by other studies[23-25] which indicate that IUD is a risk factor for vaginal infections. Furthermore, this study did not find any association between different methods of contraception and candidiasis. These results are comparable with other published data which indicated that using an IUD could increase the risk of both acute and recurrent vulvovaginal candidiasis.[26,27] However, coinfection, that is, two infections occurring simultaneously in the same case, was common. Hence, 64.8% and 5.6% of women infected with T. vaginalis were also infected with Candida sp and Gardnerella in that order or 20.9% and 4.3% of women with candidiasis also had Trichomonas and Gardnerella infections, respectively [Figure 1]. These finding are supported by Jones et al.,[28] which indicates that the prevalence of BV is significantly associated with trichomoniasis or Mendoza-Gonzalez’s studies which found that fourteen subjects had combined Candida and Gardnerella infection[29] but this was in contrast with another study.[11] The current study also demonstrated that T. vaginalis, Candida sp, and Gardnerella infections were persisting in some women after treatment. The persistence of the infections in the case may be related to improper treatment, unsanitary behaviors, and emerging of drug resistance strain of the infection agents.[30-32]
Conclusion Although our study was based only on the Papanicolaou smear test, the prevalence of T. vaginalis (0.2%), Candida sp (6.7%), and Gardnerella (0.6%) was nearly similar to asymptomatic subjects reported by others. Therefore, infections can be diagnosed in cervical smears through identification either of the organism or of characteristic cytological cellular changes. Moreover, vaginal infections produced by drug resistance of infectious agents should be noticed in treatment.
Acknowledgment We are grateful to Dr. Beejan Pourdadash, Miss. Mahjoobeh Javanbakht Faraji, Mr. Mohamad Abdolahpour, Miss Taraneh Ghaffari, Mr. Hariri, and all staff at the cancer clinics charity for their help and assistance.
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Boone JD, Erickson BK, Huh WK. New insights into cervical cancer screening. J Gynecol Oncol 2012;23:282-7. Castellsague X, Bosch FX, Munoz N. Environmental co-factors in HPV carcinogenesis. Virus Res 2002;89:191-9. Hawes SE, Kiviat NB. Are genital infections and inflammation cofactors in the pathogenesis of invasive cervical cancer? J Natl Cancer Inst 2002;94:1592-3. Guijon F, Paraskevas M, Rand F, Heywood E, Brunham R, McNicol P. Vaginal microbial flora as a cofactor in the pathogenesis of uterine cervical intraepithelial neoplasia. Int J Gynecol Obstet 1992;37:185-91. Wang PD, Lin RS. Epidemiologic differences between candidial and trichomonal infections as detected in cytologic smears in Taiwan. Public Health 1995;109:443-50. Murta EF, Silva AO, Silva EA, Adad SJ. Frequency of infectious agents for vaginitis in non-and hysterectomized women. Arch Gynecol Obstet 2005;273:152-6. Adad SJ, de Lima RV, Sawan ZT, Silva ML, de Souza MA, Saldanha JC, et al. Frequency of Trichomonas vaginalis, Candida sp and Gardnerella vaginalis in cervical-vaginal smears in four different decades. São Paulo Med J 2001;119:200-5. Lessa PR, Ribeiro SG, Lima DJ, Nicolau AI, Damasceno AK, Pinheiro AK. Presence of high-grade intraepithelial lesions among women deprived of their liberty: A documental study. Rev Lat Am Enfermagem 2012;20:354-61. Og A, Oe O, To A. Sensitivity of a papanicolaou smear in the diagnosis of candida albicans infection of the cervix. N Am J Med Sci 2010;2:97-9. Mahdavi Omran S, Rahmani Z. Frequency and etiology of vulvovaginal candidiasis in women referred to a gynecological center in Babol, lran. Int J Fertil Steril 2009;3:74-7. Klufio CA, Amoa AB, Delamare O, Hombhanje M, Kariwiga G, Igo J. Prevalence of vaginal infections with bacterial vaginosis, Trichomonas vaginalis and Candida albicans among pregnant women at the Port Moresby General Hospital Antenatal Clinic. P NG Med J 1995;38:163-71. Roeters AM, Boon ME, van Haaften M, Vernooij F, Bontekoe TR, Heintz AP. Inflammatory events as detected in cervical smears and squamous intraepithelial lesions. Diagn Cytopathol 2010;38:85-93. Omoregie R, Egbe CA, Igbarumah IO, Ogefere H, Okorie E. Prevalence and etiologic agents of female reproductive tract infection among in-patients and out-patients of a tertiary hospital in Benin city, Nigeria. N Am J Med Sci 2010;2:473-7. Mehmetoglu HC, Sadikoglu G, Ozcakir A, Bilgel N. Pap smear screening in the primary health care setting: A study from Turkey. N Am J Med Sci 2010;2:467-72. Shobeiri F, Nazari M. A prospective study of genital infections in Hamedan, Iran. Southeast Asian J Trop Med Public Health 2006;3:174-7. Boon ME, van Ravenswaay Claasen HH, Kok LP. Urbanization and baseline prevalence of genital infections including Candida, Trichomonas, and human papillomavirus and of a disturbed vaginal ecology as established in the Dutch Cervical Screening Program. Am J Obstet Gynecol 2002;187:365-9. Matini M, Rezaie S, Mohebali M, Maghsood A, Rabiee S, Fallah M, et al. Prevalence of Trichomonas vaginalis Infection in Hamadan City, Western Iran. Iran J Parasitol 2012;7:67-72.
18. Bakhtiari A, Hajian-Tilaki K, Pasha H. Genital infection by Trichomonas vaginalis in women referring to Babol health centers: Prevalence and risk factors. Iran Red Crescent Med J 2008;10:16-21. 19. Calechale A, Karimi I. The prevalence of Trichomonas vaginalis infection among patients that presented to hospitals in the Kermanshah district of Iran in 2006 and 2007. Turk J Med Sci 2010;40:971-5. 20. Gillet E, Meys JF, Verstraelen H, Verhelst R, De Sutter P, Temmerman M, et al. Association between bacterial vaginosis and cervical intraepithelial neoplasia: Systematic review and meta-analysis. Plos One 2012;7:e45201. 21. Sönmez Tamer G, Keçeli Ozcan S, Yücesoy G, Gacar G. The relation between trichomoniasis and contraceptive methods. Türkiye Parazitol Derg 2009;33:266-9. 22. Soper DE, Shoupe D, Shangold GA, Shangold MM, Gutmann J, Mercer L. Prevention of vaginal trichomoniasis by compliant use of the female condom. Sex Transm Dis 1993;20:137-9. 23. Smart S, Singal A, Mindel A. Social and sexual risk factors for bacterial vaginosis. Sex Trans Infect 2004;80:58-62. 24. Hodoglugil NN, Aslan D, Bertan M. Intrauterine device use and some issues related to sexually transmitted disease screening and occurrence. Contraception 2000;61:359-64. 25. Ceruti M, Canestrelli M, Condemi V, Piantelli G, De Paolis P, Amone F, et al. Methods of contraception and rates of genital infections. Clin Exp Obstet Gynecol 1994;21:119-23. 26. Guzel AB, Ilkit M, Akar T, Burgut R, Demir SC. Evaluation of risk factors in patients with vulvovaginal candidiasis and the value of chromID Candida agar versus CHROMagar Candida for recovery and presumptive identification of vaginal yeast species. Med Mycol 2011;49:16-25. 27. Tibaldi C, Cappello N, Latino MA, Masuelli G, Marini S, Benedetto C. Vaginal and endocervical microorganisms in symptomatic and asymptomatic non-pregnant females: Risk factors and rates of occurrence. Clin Microbiol Infect 2009;15:670-9. 28. Jones FR, Miller G, Gadea N, Meza R, Leon S, Perez J, et al. Collaborative HIV/STI Prevention Trial Group. Prevalence of bacterial vaginosis among young women in low-income populations of coastal Peru. Int J STD AIDS 2007;18:188-92. 29. Mendoza-Gonzalez A, Sanchez-Vega J, Sanchez-Peon I, Ruiz-Sanchez D, Tay-Zavala J. Frequency of Gardnerella vaginalis vaginosis and its association with other pathogens causing genital infections in the female. Ginecol obstet Mex 2001;69:272-6. 30. Dunne RL, Dunnl LA, Upcroft P, O’Donoghue PJ, Upcroft JA. Drug resistance in the sexually transmitted protozoan Trichomonas vaginalis. Cell Res 2003;13:239-49. 31. Vanden Bossche H, Dromer F, Improvisi I, Lozano-Chiu M, Rex JH, Sanglard D. Antifungal drug resistance in pathogenic fungi. Med Mycol 1998;36:119-28. 32. McLean NW, McGroarty JA. Growth inhibition of metronidazole-susceptible and metronidazole-resistant strains of Gardnerella vaginalis by Lactobacilli in vitro. Appl Environ Microbiol 1996;62:1089-92. How to cite this article: Kalantari N, Ghaffari S, Bayani M. Trichomonas, Candida , and Gardnerella in cervical smears of Iranian women for cancer screening. North Am J Med Sci 2014;6:25-9. Source of Support: Nil. Conflict of Interest: None declared.
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Trichomonas, Candida, and Gardnerella in Cervical Smears of Iranian Women for Cancer Screening Narges Kalantari, Salman Ghaffari1, Masomeh Bayani2 Cellular and Molecular Biology Research Center, 1Department of Parasitology-Mycology, Faculty of Medicine, 2Infectious Diseases and Tropical Medicine Research Center, Babol University of Medical Sciences, Babol, Iran
Abstract Background: Trichomonas vaginalis, Gardrenella vaginalis, and Candida sp are responsible for 90% of vaginitis which has been reported as important risk factors for cervical cancer. Aim: This study aimed to find the prevalence of T. vaginalis, Candida sp, and G. vaginalis in women attended the cancer clinic charity, Babol, Iran and to identify the associated risk factors. Materials and Methods: This retrospective study carried out from 1996 to July 2012 on women who attended to a cancer screening program at the cancer clinics charity, Babol, Iran. Papanicolaou test and clinical examinations were performed for each woman. In addition to Papanicolaou test results, demographic data were collected. The data were analyzed with X2 test using SPSS software, version 18. Results: In total, 2511 out of 33600 (7.5%) cases had vaginal infections. A total of 71 (0.2%), 2248 (6.7%), and 192 (0.6%) of subjects were infected by T. vaginalis, Candida sp, and Gardnerella, respectively. The highest rate of infection was seen in 20-30 and 30-40 years age group. The frequency of vaginal ulcers was higher in trichomoniasis (14.1%). Conclusion: This study demonstrated that the prevalence of T. vaginalis, Candida sp, and Gardnerella was low among the studied population. Moreover, malignant cytological alternations were not seen in any infected women.
Keywords: Candida sp, Gardnerella vaginalis, pap smear, T. vaginalis Address for correspondence: Dr. Salman Ghaffari, Ganj-Afroz Ave, Department of Parasitology-Mycology, Faculty of Medicine, Babol University of Medical Sciences, Babol, Iran. E-mail: s3ghaff[email protected]
Introduction The Papanicolaou smear has been widely accepted as the model screening test for cervical cytology. However, recent reports have suggested some limitations for the test, such as low sensitivity and high false negative rates, which have forced many to revisit the utility of cytology as a primary screening.[1] The Papanicolaou smear, which is a cost-effective test, fast and acceptable to most patients, can also be use in the diagnosis of genital tract infections. In addition to Chlamydia trachomatis, herpes simplex virus and human immunodeficiency virus, Trichomonas Access this article online Quick Response Code:
Website: www.najms.org
DOI: 10.4103/1947-2714.125861
vaginalis, is the most common sexually transmitted diseases over the world. These agents have been proposed to act as cofactors to influence the progression of cervical human papillomavirus infection to high-grade lesions and cervical cancer.[2,3] Additionally, bacterial vaginosis (BV) and Candida sp are the most frequent vaginal disorders which may play a role in cervical carcinogenesis.[4,5] Although, T. vaginalis, BV, and Candida sp are responsible for 90% of infectious vaginitis; but the prevalence found for these infections are widely varied among different populations.[6] For example, T. vaginalis and Candida sp were diagnosed in 10% and 0.5% of the cytology tests in 1968 and in 3.4% and 22.5% in 1998 in Brazil.[7] Another study demonstrated that T. vaginalis, Candida sp and Gardnerella/Mobiluncus were respectively found in 12%, 5.8%, and 21.8% of pap smears of women in a prison in Brazil.[8] However, many studies have investigated the prevalence of infectious agents among the genital tract using Papanicolaou smear, but there are few studies on large populations of women who have been referred for cervical cancer screening.
North American Journal of Medical Sciences | January 2014 | Volume 6 | Issue 1 |
25
Kalantari, et al.: Cervical infections and pap smear
In Iran, based on our best knowledge, most of the studies on genital tract infections by Papanicolaou smear were performed among symptomatic cases. The objective of this work was to study prevalence of T. vaginalis, Candida sp, and Gardnerella in women subjected to Papanicolaou smear at a clinic supported by Cancer Patients Aid Association, Babol, Iran and to identify the risk factors associated with each infective agent.
order to calculate the association of risk factors with vaginal infections.
Data analysis The data were analyzed by SPSS software, version 18.0 using descriptive analysis and Chi-squared test with a 5% statistical significance level and 95% confidence interval.
Materials and Methods
Results
Population study After obtaining approval letter with number 8929916 from the Ethical Committee of the Research Council of our organization, this retrospective study was carried out on women who attended to the cancer screening program at a clinic supported by Cancer Patients Aid Association, Babol, Iran. This center is a charity organization and established in 1996 in order to help people to increase their knowledge on cancer, diagnosis, and treatment. Breast and genital cancer were screened in the diagnostic clinic by clinical examinations and Papanicolaou test which were completely free of charge. Pap smear test was performed for any woman who attends this clinic, in addition to other clinical examinations, annually. Vaginal examination and taken smear was carried out by physician. The smears were fixed with methanol and send to clinical pathology laboratory. The smears were evaluated by a pathologist. This clinic also collects demographic data and other information based on clinical examinations and the Pap smear reports using a Bethesda system. This information includes the sample adequacy, the type of epithelium (e.g. squamous, glandular, and metaplastic), benign cellular alterations (e.g. inflammation), and the type of genital infections (e.g. T. vaginalis and Candida sp). Between 1996 and July 2012, the information from 33600 cases was archived. The files for all of the cases of T. vaginalis, Candida sp, and Gardnerella infections were retrieved. Also, files of 200 women without any infection (control group) were randomly recovered in
Overall, 2511 out of 33600 (7.5%) cases had vaginal infection. A total of 71 (0.2%), 2248 (6.7%), and 192 (0.6%) of the women were infected by T. vaginalis, Candida, and Gardnerella, respectively. A total of 142 out of 2511 (5.7%) cases had mixed infection. The minimum and maximum of age among women with trichomoniasis was 18 and 61 years and the mean of age was 34.7 years. The mean age of women infected with Candida and Gardnerella were 32.7 ± 8 and 32.8 ± 8.5, respectively which ranged from 14 to 67 and 17-60 years in that order. The mean age of women with coinfection and healthy women (control group) was 32.4 ± 9.2 and 34.6 ± 10.5 years, respectively which ranged from 17 to 67 and 18 to 73 years in that order. The age of one case infected with T. vaginalis and 12 cases infected with Candida were obtained as missing data. The highest infection rate of T. vaginalis and Candida were observed in the 30-40 age groups and for Gardnerella was seen in the 20-30 years age group. The highest rate of coinfection was also seen in the 20-30 years age group. The highest frequency rate of women in the control group was demonstrated in the 20-30 years age group followed by the 30-40 age groups [Table 1]. The lowest rate of trichomoniasis (1.4%) was demonstrated in women who used condom as their preferred choice of contraception, while the highest rate (2.7%) was seen in women who used other forms of contraception such as tubectomy or oral contraceptives. Furthermore, 13.8% of women who used intrauterine device (IUD) were infected with
Table 1: Prevalence of Trichomonas vaginalis, Candida sp, Gardnerella and coinfection in women attending to the cancer clinics charity, Babol, Iran, by age Infection Age group (years)
Mean±
T. vaginalis Candida Gardnerella Coinfection Control
34.7±10.2 32.7±8 32.8±8.5 32.4±9.2 34.6±10.5
N%
P value
50
Total
57.1 873.9 105.2 107 157.4
2028.6 86938.9 7941.1 6143 6633
2738.6 92341.2 6835.4 5135.9 6030
1420 31914.3 3116.2 1611.3 4321.6
45.7 381.7 42.1 42.8 168
70100 2236100 192100 142100 200100
0.09 0.001 0. 95 -
N. B: The mean age, standard deviation, and frequency of healthy women (control group) among different age group also mentioned. The numbers of trichomoniasis and candidiasis cases were 71 and 2248, but there was missing data on age of 1 tricomoniasis and 12 candidiasis cases. T. vaginalis: Trichomonas vaginalis
26
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Kalantari, et al.: Cervical infections and pap smear
This study demonstrated that 64.8% and 5.6% of women infected with T. vaginalis were also infected with Candida sp and Gardnerella, respectively. Coinfection was also demonstrated in women with candidiasis and Gardnerella infection [Figure 1]. The findings obtained in this study showed that about 4%-8.3% of
infected women with T. vaginalis remained infected in subsequent refers. Also, 59.3% of infected with Candida sp and 51.2% of infected women with Candida sp and Gardnerella remained infected in the next refer. Malignant cytological alternations were not seen in any infected women. 120 100 Percentage
Gardnerella and the lowest infection rate was observed in those used condom and other methods (0.05%). The infection rate of candidiasis was approximately similar in women who used different contraception methods and ranged from 82.7% to 87.3% [Table 2]. A total of 1.2% and 12.3% of healthy women used condom and IUD, respectively and the rest used other methods. Vaginal ulcers were demonstrated in 14.1% (10/71), 7.4% (167/2246), and 8.9% (17/192) of women infected with T. vaginalis, Candida sp, and Gardnerella, respectively [Table 2 and Figure 1]. Prevalence of genital infections in association with other factors including number of gravid, abortion, inflammation, residency, and presence of squamous cells are also shown in Table 2.
100
80
100
100
64.8
60
48.4
40 20
5.6
20.9
14.1
4.3 7.4
2.1
0
8.9
1
Figure 1: Prevalence of coinfection and ulcer in women attending to a clinics supported by Cancer Patients Aid Association, Babol, Iran. T, I, C, G, and U are Trichomonas, Infection, Candida, cancer Gardnerella, and ulcer, in that order
Table 2: Prevalence of Trichomonas vaginalis, Candida sp, and Gardnerella related to some risk factors and sign, in women attending to a clinics supported by cancer patients aid association, Babol, Iran Risk Infection Inflammation Severe Moderate Mild no Ulcer Yes No Squamous cells Yes No Abortion Yes No Gravid no 3 Contraception IUD Condom Natural and other Residency Urban Rural
Control
P value
18 9.4 89 46.6 189 6634.6
-
0
1677.4 207993
178.9 17591.1
-
a, 0.3; b, 0.002; c, 0.9
0
4100
1100
-
1725.8 4974.2
52924.3 164776
4423.9 14076.1
56 28 14472
a, 0.9; b, 0.000; c, 0.8
1322.8 245.6 1831.6
47423 112555 46322.4
3318.7 9453.1 5028.2
3518.8 9048.4 6132.8
a, 0.35; b, 0.16; c, 0.000
2/942.1 4/2861.4 55/20062.7
81/9882.7 255/29287.3 1699/203383.6
13/9413.8 15/2850.05 138/19876.9
212.9 61.2 15586.1
a, 0.01; b, 0.02; c, 0.05
6088.2 811.8
193388 27712.5
16988 2312
179 89.5 2110.5
a, 0.7; b, 0.09; c, 0.9
N% T. vaginalisaa
Candidab
Gardnerellac
79.9 37 52.1 2129.6 68.4
1516.8 88539.7 77334.6 42218.9
1014.1 6185.9
N.B. P value arranged in order of Trichomonas vaginalis, Candida sp, and Gardnerella infections. Note in regarding the association between candidiasis and number of gravidity and abortion and contraception, the P values were 0.000 and 0.02 which may resulted from number of cases in non infected women (200 cases). Also notice that missing data of Gravid number and contraception in noninfected population. a, b, and c represent P value of Trichomonas vaginalis, Candida sp and Gardnerella and the factors, respectively. IUD: Intrauterine device, T. vaginalis: Trichomonas vaginalis
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Kalantari, et al.: Cervical infections and pap smear
Discussion This study found that infection rate among the women attending to cancer screening program was low (7.5%). This result was obtained by Papanicolaou test which has some limitations such as less sensitivity.[1-9] It also demonstrated that Candida sp was the main cause of vaginal infection (6.7%) and T. vaginalis (0.2%) and Gardnerella (0.6%) had low prevalence rates among these women. Although, our study is confirmed by publications which indicate that candidiasis is the most common vaginal infection in most countries, but the prevalence rate of infective agents obtained from the current study was lower in comparison with other studies in the word and Iran.[10-13] For example, one study reported that the amount of candidiasis, trichomoniasis, and Gardnerella infection were 9.8%, 1.9%, and 0.7% in pap smear of women who participated in screening. [12] Adad et al., [7] studied 20,356 cases using Papanicolaou test in four decades in Brazil and found that low and high indices of infections belong to trichomoniasis (3.4%) and candidiasis (22.5%) from 1988 to 1998. Mehmetoglu et al.,[14] reported that vaginal infection identified in 17.7% (59 out of 332) of the cases by Pap smear and the prevalence of trichomoniasis was 0.6%. Also, Lessa et al.,[8] studied 672 patient records and demonstrated that the main cervical-vaginal colonization was due to Gardnerella/Mobiluncus (21.8%), followed by T. vaginalis (12%), and Candida sp (5.8%). Furthermore, the prevalence of BV, candidiasis, and trichomoniasis in asymptomatic subjects were found 0.4%, 1.1%, and 0.7%, in that order.[15] Although, different diagnostic methods were used in this study, its findings support our results. With consideration of the prevalence rate of T. vaginalis, Candida, and Gardnerella infections among asymptomatic cases in several reports,[5,13,15,16] the differences of the studied populations are the main possible explanation for dissimilarity between our findings and other publications. The current study showed that the highest prevalence rate of T. vaginalis (38.6%) and Candida (41.3%) infections and Gardnerella infection (41.1%) was seen in 20-30 years and 30-40 and age group, respectively. This finding is in agreement with results obtained from several studies which indicated that highest rate of trichomoniasis demonstrated in women at sexually active ages.[17-19] or BV was observed at reproductive ages.[20] This study found that, although moderate inflammation was a general manifestation in infected women, [8] trichomoniasis causes more inflammation (mild to sever) and ulcers in comparison to candidiasis and Gardnerella [Table 2]. Indeed, Trichomonas, Candida, and Gardnerella are considered as the simultaneous inflammatory events in genital tract.[12] 28
In regard to T. vaginalis and Gardnerella infections, the analysis of the behavioral marker showed that the prevalence of the infection was significantly lower in women whose husbands use condom as a contraception method. These results are in agreement with other publications which indicate that the rate of trichomoniasis and BV was less in those whose husbands used condoms than who did not.[18-22] Moreover, the current study found that the Gardnerella infection may be associated with IUD. This finding is supported by other studies[23-25] which indicate that IUD is a risk factor for vaginal infections. Furthermore, this study did not find any association between different methods of contraception and candidiasis. These results are comparable with other published data which indicated that using an IUD could increase the risk of both acute and recurrent vulvovaginal candidiasis.[26,27] However, coinfection, that is, two infections occurring simultaneously in the same case, was common. Hence, 64.8% and 5.6% of women infected with T. vaginalis were also infected with Candida sp and Gardnerella in that order or 20.9% and 4.3% of women with candidiasis also had Trichomonas and Gardnerella infections, respectively [Figure 1]. These finding are supported by Jones et al.,[28] which indicates that the prevalence of BV is significantly associated with trichomoniasis or Mendoza-Gonzalez’s studies which found that fourteen subjects had combined Candida and Gardnerella infection[29] but this was in contrast with another study.[11] The current study also demonstrated that T. vaginalis, Candida sp, and Gardnerella infections were persisting in some women after treatment. The persistence of the infections in the case may be related to improper treatment, unsanitary behaviors, and emerging of drug resistance strain of the infection agents.[30-32]
Conclusion Although our study was based only on the Papanicolaou smear test, the prevalence of T. vaginalis (0.2%), Candida sp (6.7%), and Gardnerella (0.6%) was nearly similar to asymptomatic subjects reported by others. Therefore, infections can be diagnosed in cervical smears through identification either of the organism or of characteristic cytological cellular changes. Moreover, vaginal infections produced by drug resistance of infectious agents should be noticed in treatment.
Acknowledgment We are grateful to Dr. Beejan Pourdadash, Miss. Mahjoobeh Javanbakht Faraji, Mr. Mohamad Abdolahpour, Miss Taraneh Ghaffari, Mr. Hariri, and all staff at the cancer clinics charity for their help and assistance.
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Kalantari, et al.: Cervical infections and pap smear
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18. Bakhtiari A, Hajian-Tilaki K, Pasha H. Genital infection by Trichomonas vaginalis in women referring to Babol health centers: Prevalence and risk factors. Iran Red Crescent Med J 2008;10:16-21. 19. Calechale A, Karimi I. The prevalence of Trichomonas vaginalis infection among patients that presented to hospitals in the Kermanshah district of Iran in 2006 and 2007. Turk J Med Sci 2010;40:971-5. 20. Gillet E, Meys JF, Verstraelen H, Verhelst R, De Sutter P, Temmerman M, et al. Association between bacterial vaginosis and cervical intraepithelial neoplasia: Systematic review and meta-analysis. Plos One 2012;7:e45201. 21. Sönmez Tamer G, Keçeli Ozcan S, Yücesoy G, Gacar G. The relation between trichomoniasis and contraceptive methods. Türkiye Parazitol Derg 2009;33:266-9. 22. Soper DE, Shoupe D, Shangold GA, Shangold MM, Gutmann J, Mercer L. Prevention of vaginal trichomoniasis by compliant use of the female condom. Sex Transm Dis 1993;20:137-9. 23. Smart S, Singal A, Mindel A. Social and sexual risk factors for bacterial vaginosis. Sex Trans Infect 2004;80:58-62. 24. Hodoglugil NN, Aslan D, Bertan M. Intrauterine device use and some issues related to sexually transmitted disease screening and occurrence. Contraception 2000;61:359-64. 25. Ceruti M, Canestrelli M, Condemi V, Piantelli G, De Paolis P, Amone F, et al. Methods of contraception and rates of genital infections. Clin Exp Obstet Gynecol 1994;21:119-23. 26. Guzel AB, Ilkit M, Akar T, Burgut R, Demir SC. Evaluation of risk factors in patients with vulvovaginal candidiasis and the value of chromID Candida agar versus CHROMagar Candida for recovery and presumptive identification of vaginal yeast species. Med Mycol 2011;49:16-25. 27. Tibaldi C, Cappello N, Latino MA, Masuelli G, Marini S, Benedetto C. Vaginal and endocervical microorganisms in symptomatic and asymptomatic non-pregnant females: Risk factors and rates of occurrence. Clin Microbiol Infect 2009;15:670-9. 28. Jones FR, Miller G, Gadea N, Meza R, Leon S, Perez J, et al. Collaborative HIV/STI Prevention Trial Group. Prevalence of bacterial vaginosis among young women in low-income populations of coastal Peru. Int J STD AIDS 2007;18:188-92. 29. Mendoza-Gonzalez A, Sanchez-Vega J, Sanchez-Peon I, Ruiz-Sanchez D, Tay-Zavala J. Frequency of Gardnerella vaginalis vaginosis and its association with other pathogens causing genital infections in the female. Ginecol obstet Mex 2001;69:272-6. 30. Dunne RL, Dunnl LA, Upcroft P, O’Donoghue PJ, Upcroft JA. Drug resistance in the sexually transmitted protozoan Trichomonas vaginalis. Cell Res 2003;13:239-49. 31. Vanden Bossche H, Dromer F, Improvisi I, Lozano-Chiu M, Rex JH, Sanglard D. Antifungal drug resistance in pathogenic fungi. Med Mycol 1998;36:119-28. 32. McLean NW, McGroarty JA. Growth inhibition of metronidazole-susceptible and metronidazole-resistant strains of Gardnerella vaginalis by Lactobacilli in vitro. Appl Environ Microbiol 1996;62:1089-92. How to cite this article: Kalantari N, Ghaffari S, Bayani M. Trichomonas, Candida , and Gardnerella in cervical smears of Iranian women for cancer screening. North Am J Med Sci 2014;6:25-9. Source of Support: Nil. Conflict of Interest: None declared.
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